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Transarterial Radioembolization as Bridge Therapy for Patients with Early Stage Hepatocellular Carcinoma Undergoing Liver Transplantation and Universiy of Florida Experience
Mo1420
Mo1418 A ROLE OF SCHEDULED SECOND TACE IN EARLY STAGE HEPATOCELLULAR CARCINOMA SHOWING COMPLETE RESPONSE AFTER THE FIRST TACE Moon Seok Choi, Jung Hee Kim, Dong Hyun Sinn, Wonseok Kang, Geum-Youn Gwak, Yong-Han Paik, Joon Hyeok Lee, Kwang Cheol Koh, Seung Woon Paik Background/Aims: We investigated the outcome of early stage hepatocellular carcinoma (HCC) patients who showed complete response (CR) after the first transarterial chemoembolization (TACE), with focus on the role of scheduled repetition of TACE. Methods: A total of 178 patients with early stage HCC who were initially treated with TACE and showed CR by modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria at one month follow-up computed tomography (CT) were analyzed. Among them, 90 patients received scheduled repetition of TACE in the absence of viable tumor on CT. Results: During a median follow-up of 4.6 years (range: 0.4 - 8.8 years), mortality was observed in 71 patients (39.9%). The overall recurrence free and local recurrence free survival rates at 1 year were 44.4% and 56.2. In multivariable model, scheduled repetition of TACE was an independent factor associated with survival [hazard ratio (95% confidence interval): 0.56 (0.34-0.93), P=0.025]. When stratified to the BCLC stage, scheduled repetition of TACE was associated with favorable survival rate in BCLC stage A patients, but not in BCLC 0 patients. Conclusion: Scheduled repetition of TACE was associated with better survival for early stage HCC showing CR after first TACE, especially for BCLC stage A patients.
Introduction: Liver transplantation (LT) is considered the best curative treatment option for hepatocellular carcinoma (HCC). For patients with HCC to qualify for LT exception points their tumor must fulfill the Milan criteria (1 tumor <5 cm or 3 tumors <3cm) and remain within the criteria. Locoregional therapies (LRT) are often used to maintain HCC within criteria, however, the optimal treatment modality is not clearly defined. Transarterial radiomebolization (TARE) is increasingly being used in patients listed with HCC, although there is a paucity of data comparing outcomes of TARE to more established LRT. Objectives: To assess the impact of TARE versus non-TARE modalities on post-transplant outcomes including survival and tumor recurrence in patients listed for liver transplantation with HCC within the Milan criteria. Methods: We retrospectively evaluated patients on the UF liver transplant list with HCC since April 2012 who received pre-transplant LRT to determine characteristics and outcomes for the entire cohort. Patients who received TARE were then compared to those who did not receive TARE (non-TARE group) regarding post-transplant survival and tumor recurrence. Secondary endpoints of wait time on the list, presence of viable tumor on explant, presence of microvascular invasion on explant, tumor recurrence, and rate of delisting were determined. Results: A total of 97 patients were listed for liver transplant with HCC within the Milan criteria and received LRT. LT was performed in 60 patients (61.9%). Of the 33 patients who received TARE 15 were transplanted, while of the 64 patients who received non-TARE 45 were transplanted. The mean wait time for LT was 274.6 and 269.2 days, mean follow up period was 11.4 and 19.6 months, and survival rates at 2 years were 91.7% and 82.5% (p=0.83) in TARE and non-TARE respectively. Presence of viable tumor on liver explant was 69.2% and 80.0% (p=0.67), microvascular invasion on explant 0% and 22% (p=0.056), tumor recurrence was 0% and 6.7% (p=0.31), rate of delisting was 50.0% and 52.6% and rate of death while on the waiting list was 16.7% and 15.8% for TARE and non-TARE, respectively. Conclusions: We found a similar posttransplant survival and rate of tumor recurrence when comparing TARE to non-TARE treatments. No major differences in wait times, tumor viability on explant, and delisting were detected between the two treatments. Both therapies appear comparable for maintaining patients with HCC on the waiting list with similar outcomes.
Mo1421 MALE SEX IS A RISK FACTOR FOR POORER LONG-TERM OVERALL SURVIVAL FOR WHITE PATIENTS WITH HEPATOCELLULAR CARCINOMA (HCC) BUT NOT FOR BLACK PATIENTS WITH HCC Jacqueline Estevez, Jennifer Leong, Ju Dong Yang, Pauline Nguyen, Nasra H. Giama, Lewis R. Roberts, Myron Schwartz, Mindie H. Nguyen Background: According to studies done on the Surveillance, Epidemiology, and End Results (SEER) registry, patients who are male or of non-Hispanic black race have a higher incidence rate of hepatocellular carcinoma (HCC) and worse survival. Our aim was to characterize the influence of gender on long-term survival in black and white patients with adjustment for effect of liver etiology and function, important confounders that are not available in the SEER registry. Methods: This is a case cohort study of 578 consecutive non-Hispanic black patients with HCC and 578 matched non-Hispanic white patients (by year of HCC diagnosis from 1991 to 2016). Clinical data was obtained through individual chart review, and death was confirmed via National Death Index search. Results: In total, 307 were female and 849 were male. About 70% of the black patients and 77% of the white patients were male. Overall 10-year survival was lower for males compared to females (Figure 1), with male sex as an independent risk factor for poorer survival on multivariate analysis (hazard ratio (HR) 1.35, 95% confidence interval (CI) 1.07-1.71, p= 0.01) controlling for age, diagnosis year, insurance type, BCLC, Child's class, alcohol use, and treatment type. This difference was also seen within each race. Among white patients, males had worse survival compared to females (p=0.011), and there was a trend towards worse 10-year survival for males among black patients (p= 0.06). However, within each gender, 10-year survival was similar for both white and black patients (p=0.43 for female and p=0.74 for male). The difference in survival among white males appeared to occur in the older patient cohort (age ≥55) with males having worse 10-year survival in this subgroup ( p= 0.02, n=489). Survival was similar for both genders among white patients younger than 55 ( p= 0.19, n=87). Indeed, on multivariate analysis for survival among whites patients ≥55, male sex remains a significant risk factor (HR 1.82, 95% CI 1.23-2.68, p<0.01) even after controlling for age, diagnosis year, insurance type, BCLC, Child's class, alcohol use, and treatment type. For black patients, there was a trend towards worse 10-year survival for males ( p= 0.06), but there was no survival difference by age in this racial group. Conclusion: Overall 10-year survival was poorer for male HCC patients and this gender difference was observed within each racial group (black and white). However, this gender difference appeared to have come largely from the older patients for the white cohort, while the gender effect appeared to be similar across the different age groups in the black cohort. Male gender was a significant independent risk factor for mortality in white patients, especially older white patients. Male gender is not only a risk factor for HCC but also a risk factor for poorer survival in older white patients with HCC.
Mo1419 POOR EFFECTIVENESS OF ULTRASOUND SURVEILLANCE PRIOR TO DIAGNOSIS OF HCC IN A PREDOMINATELY AFRICAN AMERICAN POPULATION Brian Rutledge, Neha Sahni, Paul H. Naylor, Sindhuri Benjaram, Zara Hussain, Philip Philip, Murray N. Ehrinpreis, Milton G. Mutchnick Background: We have previously reported a 23% incidence in hepatocellular carcinoma (HCC) in African Americans (AA) with chronic hepatitis C (CHC) in our urban GI clinic. We also reported that only 20% of patients had their HCC detected in a surveillance protocol and that an elevated APRI was a surrogate marker for the need to increase surveillance. Given the difficulty in establishing a surveillance program, we evaluated factors which might contribute to poor surveillance. We also evaluated the hypothesis that a clear Ultrasound (US) within 1 year of diagnosis of HCC would result in a smaller tumor at diagnosis as compared to patients diagnosed without a previous US. Methods: The EMR of a large health care provider was used to identify patients with HCC between 2010 and 2015. Race was self-reported, and the data was analyzed as AA or Non-AA. An ultrasound assessment was defined as "clear" if there was no mention of mass(es) with suspicion of HCC. Tumor size was defined by imaging with <5 cm being defined as "small". Results: The 238 HCC patients identified were primarily AA (78%), male (76%) and with an average age of 62 years. HCV was more likely to be a risk factor for the development of HCC in AA as compared to nonAA (92% vs 67%; p<0.005). The number of patients with an US within 1 year of HCC diagnosis was small (24/181= 13%) and there was only a 2 fold difference with respect to a small tumor at diagnosis compared to no US within 1 year (66% vs 34%; p<0.005). The primary reason for surveillance (ie US within 1 year) was a physician of record (16% vs 3% for no physician of record; p<0.001) with a trend towards GI physicians being more likely to have ordered a US than primary care physicians (PCP; 30% vs 20%). Factors which did not influence the 1 year US surveillance included race, gender, year of diagnosis, risk factor and HCV status. Conclusions: Regardless of race, the majority of HCC patients in the DMC database were diagnosed at first visit rather than in a surveillance protocol. Although a clear US, 1 year prior to diagnosis improved the probably of detecting a smaller tumor at diagnosis, it offered only a 2 fold increase in this predominately AA population. Thus, surveillance at a 6 month interval may be required to significantly improve early detection of tumors in a predominately AA population. Unfortunately, since none of the patients in our dataset had an US every 6 months, this does not appear to be a reasonable option for this population. Since the majority of patients has hepatitis C virus infection as their risk factor, prompt treatment and clearance of the virus will provide the best option for reducing HCC incidende in this population. Supported in part by an Investigator Initiated Research Grant from Gilead Sciences.
S-1177
AASLD Abstracts
AASLD Abstracts
TRANSARTERIAL RADIOEMBOLIZATION AS BRIDGE THERAPY FOR PATIENTS WITH EARLY STAGE HEPATOCELLULAR CARCINOMA UNDERGOING LIVER TRANSPLANTATION AND UNIVERSIY OF FLORIDA EXPERIENCE Andreas G. Zori, Media N. Ismael, Alpna R. Limaye, Amitabh Suman, Consuelo Soldevila-Pico, Kenneth A. Andreoni, Elizabeth M. Thomas, Mark W. Johnson, Brian S. Geller, Jeffrey D. Vogel, Mark Horvath, Darren W. Postoak, Roniel Cabrera
Mo1418 A ROLE OF SCHEDULED SECOND TACE IN EARLY STAGE HEPATOCELLULAR CARCINOMA SHOWING COMPLETE RESPONSE AFTER THE FIRST TACE Moon Seok Choi, Jung Hee Kim, Dong Hyun Sinn, Wonseok Kang, Geum-Youn Gwak, Yong-Han Paik, Joon Hyeok Lee, Kwang Cheol Koh, Seung Woon Paik Background/Aims: We investigated the outcome of early stage hepatocellular carcinoma (HCC) patients who showed complete response (CR) after the first transarterial chemoembolization (TACE), with focus on the role of scheduled repetition of TACE. Methods: A total of 178 patients with early stage HCC who were initially treated with TACE and showed CR by modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria at one month follow-up computed tomography (CT) were analyzed. Among them, 90 patients received scheduled repetition of TACE in the absence of viable tumor on CT. Results: During a median follow-up of 4.6 years (range: 0.4 - 8.8 years), mortality was observed in 71 patients (39.9%). The overall recurrence free and local recurrence free survival rates at 1 year were 44.4% and 56.2. In multivariable model, scheduled repetition of TACE was an independent factor associated with survival [hazard ratio (95% confidence interval): 0.56 (0.34-0.93), P=0.025]. When stratified to the BCLC stage, scheduled repetition of TACE was associated with favorable survival rate in BCLC stage A patients, but not in BCLC 0 patients. Conclusion: Scheduled repetition of TACE was associated with better survival for early stage HCC showing CR after first TACE, especially for BCLC stage A patients.
Introduction: Liver transplantation (LT) is considered the best curative treatment option for hepatocellular carcinoma (HCC). For patients with HCC to qualify for LT exception points their tumor must fulfill the Milan criteria (1 tumor <5 cm or 3 tumors <3cm) and remain within the criteria. Locoregional therapies (LRT) are often used to maintain HCC within criteria, however, the optimal treatment modality is not clearly defined. Transarterial radiomebolization (TARE) is increasingly being used in patients listed with HCC, although there is a paucity of data comparing outcomes of TARE to more established LRT. Objectives: To assess the impact of TARE versus non-TARE modalities on post-transplant outcomes including survival and tumor recurrence in patients listed for liver transplantation with HCC within the Milan criteria. Methods: We retrospectively evaluated patients on the UF liver transplant list with HCC since April 2012 who received pre-transplant LRT to determine characteristics and outcomes for the entire cohort. Patients who received TARE were then compared to those who did not receive TARE (non-TARE group) regarding post-transplant survival and tumor recurrence. Secondary endpoints of wait time on the list, presence of viable tumor on explant, presence of microvascular invasion on explant, tumor recurrence, and rate of delisting were determined. Results: A total of 97 patients were listed for liver transplant with HCC within the Milan criteria and received LRT. LT was performed in 60 patients (61.9%). Of the 33 patients who received TARE 15 were transplanted, while of the 64 patients who received non-TARE 45 were transplanted. The mean wait time for LT was 274.6 and 269.2 days, mean follow up period was 11.4 and 19.6 months, and survival rates at 2 years were 91.7% and 82.5% (p=0.83) in TARE and non-TARE respectively. Presence of viable tumor on liver explant was 69.2% and 80.0% (p=0.67), microvascular invasion on explant 0% and 22% (p=0.056), tumor recurrence was 0% and 6.7% (p=0.31), rate of delisting was 50.0% and 52.6% and rate of death while on the waiting list was 16.7% and 15.8% for TARE and non-TARE, respectively. Conclusions: We found a similar posttransplant survival and rate of tumor recurrence when comparing TARE to non-TARE treatments. No major differences in wait times, tumor viability on explant, and delisting were detected between the two treatments. Both therapies appear comparable for maintaining patients with HCC on the waiting list with similar outcomes.
Mo1421 MALE SEX IS A RISK FACTOR FOR POORER LONG-TERM OVERALL SURVIVAL FOR WHITE PATIENTS WITH HEPATOCELLULAR CARCINOMA (HCC) BUT NOT FOR BLACK PATIENTS WITH HCC Jacqueline Estevez, Jennifer Leong, Ju Dong Yang, Pauline Nguyen, Nasra H. Giama, Lewis R. Roberts, Myron Schwartz, Mindie H. Nguyen Background: According to studies done on the Surveillance, Epidemiology, and End Results (SEER) registry, patients who are male or of non-Hispanic black race have a higher incidence rate of hepatocellular carcinoma (HCC) and worse survival. Our aim was to characterize the influence of gender on long-term survival in black and white patients with adjustment for effect of liver etiology and function, important confounders that are not available in the SEER registry. Methods: This is a case cohort study of 578 consecutive non-Hispanic black patients with HCC and 578 matched non-Hispanic white patients (by year of HCC diagnosis from 1991 to 2016). Clinical data was obtained through individual chart review, and death was confirmed via National Death Index search. Results: In total, 307 were female and 849 were male. About 70% of the black patients and 77% of the white patients were male. Overall 10-year survival was lower for males compared to females (Figure 1), with male sex as an independent risk factor for poorer survival on multivariate analysis (hazard ratio (HR) 1.35, 95% confidence interval (CI) 1.07-1.71, p= 0.01) controlling for age, diagnosis year, insurance type, BCLC, Child's class, alcohol use, and treatment type. This difference was also seen within each race. Among white patients, males had worse survival compared to females (p=0.011), and there was a trend towards worse 10-year survival for males among black patients (p= 0.06). However, within each gender, 10-year survival was similar for both white and black patients (p=0.43 for female and p=0.74 for male). The difference in survival among white males appeared to occur in the older patient cohort (age ≥55) with males having worse 10-year survival in this subgroup ( p= 0.02, n=489). Survival was similar for both genders among white patients younger than 55 ( p= 0.19, n=87). Indeed, on multivariate analysis for survival among whites patients ≥55, male sex remains a significant risk factor (HR 1.82, 95% CI 1.23-2.68, p<0.01) even after controlling for age, diagnosis year, insurance type, BCLC, Child's class, alcohol use, and treatment type. For black patients, there was a trend towards worse 10-year survival for males ( p= 0.06), but there was no survival difference by age in this racial group. Conclusion: Overall 10-year survival was poorer for male HCC patients and this gender difference was observed within each racial group (black and white). However, this gender difference appeared to have come largely from the older patients for the white cohort, while the gender effect appeared to be similar across the different age groups in the black cohort. Male gender was a significant independent risk factor for mortality in white patients, especially older white patients. Male gender is not only a risk factor for HCC but also a risk factor for poorer survival in older white patients with HCC.
Mo1419 POOR EFFECTIVENESS OF ULTRASOUND SURVEILLANCE PRIOR TO DIAGNOSIS OF HCC IN A PREDOMINATELY AFRICAN AMERICAN POPULATION Brian Rutledge, Neha Sahni, Paul H. Naylor, Sindhuri Benjaram, Zara Hussain, Philip Philip, Murray N. Ehrinpreis, Milton G. Mutchnick Background: We have previously reported a 23% incidence in hepatocellular carcinoma (HCC) in African Americans (AA) with chronic hepatitis C (CHC) in our urban GI clinic. We also reported that only 20% of patients had their HCC detected in a surveillance protocol and that an elevated APRI was a surrogate marker for the need to increase surveillance. Given the difficulty in establishing a surveillance program, we evaluated factors which might contribute to poor surveillance. We also evaluated the hypothesis that a clear Ultrasound (US) within 1 year of diagnosis of HCC would result in a smaller tumor at diagnosis as compared to patients diagnosed without a previous US. Methods: The EMR of a large health care provider was used to identify patients with HCC between 2010 and 2015. Race was self-reported, and the data was analyzed as AA or Non-AA. An ultrasound assessment was defined as "clear" if there was no mention of mass(es) with suspicion of HCC. Tumor size was defined by imaging with <5 cm being defined as "small". Results: The 238 HCC patients identified were primarily AA (78%), male (76%) and with an average age of 62 years. HCV was more likely to be a risk factor for the development of HCC in AA as compared to nonAA (92% vs 67%; p<0.005). The number of patients with an US within 1 year of HCC diagnosis was small (24/181= 13%) and there was only a 2 fold difference with respect to a small tumor at diagnosis compared to no US within 1 year (66% vs 34%; p<0.005). The primary reason for surveillance (ie US within 1 year) was a physician of record (16% vs 3% for no physician of record; p<0.001) with a trend towards GI physicians being more likely to have ordered a US than primary care physicians (PCP; 30% vs 20%). Factors which did not influence the 1 year US surveillance included race, gender, year of diagnosis, risk factor and HCV status. Conclusions: Regardless of race, the majority of HCC patients in the DMC database were diagnosed at first visit rather than in a surveillance protocol. Although a clear US, 1 year prior to diagnosis improved the probably of detecting a smaller tumor at diagnosis, it offered only a 2 fold increase in this predominately AA population. Thus, surveillance at a 6 month interval may be required to significantly improve early detection of tumors in a predominately AA population. Unfortunately, since none of the patients in our dataset had an US every 6 months, this does not appear to be a reasonable option for this population. Since the majority of patients has hepatitis C virus infection as their risk factor, prompt treatment and clearance of the virus will provide the best option for reducing HCC incidende in this population. Supported in part by an Investigator Initiated Research Grant from Gilead Sciences.
S-1177
AASLD Abstracts
AASLD Abstracts
TRANSARTERIAL RADIOEMBOLIZATION AS BRIDGE THERAPY FOR PATIENTS WITH EARLY STAGE HEPATOCELLULAR CARCINOMA UNDERGOING LIVER TRANSPLANTATION AND UNIVERSIY OF FLORIDA EXPERIENCE Andreas G. Zori, Media N. Ismael, Alpna R. Limaye, Amitabh Suman, Consuelo Soldevila-Pico, Kenneth A. Andreoni, Elizabeth M. Thomas, Mark W. Johnson, Brian S. Geller, Jeffrey D. Vogel, Mark Horvath, Darren W. Postoak, Roniel Cabrera